Hepatitis C: migrant health guide
Advice and guidance on the health needs of migrant patients for healthcare practitioners.
Main messages
Consider screening patients from countries with a higher prevalence of hepatitis C virus (HCV) than the UK, particularly those where the prevalence of HCV is considerably higher or if other risk factors apply.
Consider screening contacts of HCV-infected patients.
Refer individuals identified as positive for specialist assessment.
Background
The hepatitis C virus (HCV) causes hepatitis (inflammation of the liver) and can lead to chronic liver disease.
The World Health Organization estimates that globally 58 million people have chronic hepatitis C, with about 1.5 million new infections occurring per year.
Regions with the highest prevalence of hepatitis C include the Eastern Mediterranean region and European region.
On a global scale, the UK is considered to be a relatively low prevalence country. Approximately 89,000 people in England were estimated to be living with chronic hepatitis C infection in 2019.
Surveillance and research studies in England have found that individuals of South Asian origin are among those at increased risk of hepatitis C infection.
Symptoms
During acute infection many people have no symptoms, while others can experience:
- fever
- fatigue
- decreased appetite
- nausea
- vomiting
- abdominal pain
- dark urine
- grey-coloured faeces
- joint pain
- jaundice (yellowing of the skin and the whites of the eyes)
- ‘flu-like’ symptoms
HCV is transmitted by contact with infected blood, and is spread by:
- sharing or use of contaminated equipment during injecting drug use or intranasal drug use
- receiving infectious blood (via transfusion) or infectious blood products (for example clotting factors)
- the reuse or inadequate sterilisation of medical equipment
- needlestick or other sharps injuries
- tattooing and body piercing
Minor transmission routes include:
- vertical transmission (mother to baby)
- sexual transmission
The average incubation period is between 2 weeks to 6 months.
Approximately 15% to 45% of infected people clear their infections naturally within the first 6 months of infection, but they do not become immune to future HCV infection.
The remainder will develop chronic hepatitis C infection, which means they:
- require treatment
- will be infectious to others
- can develop chronic liver disease including cirrhosis and carcinoma
See ‘Hepatitis C: guidance, data and analysis’.
Testing
Sample required for diagnosis
Send a clotted blood (2ml to 6ml) sample to your local laboratory for antibody testing. If positive, the laboratory will test to detect viral RNA, and will require a second sample for confirmation.
See PHE’s Hepatitis C: information for GPs.
Offer testing to anyone at risk of hepatitis C infection, including:
- current and past injecting drug users
- recipients of blood transfusions before September 1991 and or those who have received treatment with an NHS blood product before 1986 in England
- people born or raised in a high prevalence country
- babies whose mothers have HCV infection
- prisoners and young offenders
- looked after children
- those living in hostels or who are homeless
- HIV-positive men who have sex with men
- close contacts of someone with HCV infection
- people with abnormal liver function tests (LFT)
Post-test discussion
Refer to the following guidance for post-test discussion.
Negative antibody result
Further testing is required if the last exposure risk occurred in the preceding 3 month ‘window period’.
Discuss ways of avoiding infection in the future.
Positive antibody result
Confirm positive antibody results on a second blood sample, and arrange tests for HCV RNA.
Advise not to donate blood or carry an organ donor card.
Positive HCV RNA result
Refer patients to a specialist for further assessment.
Stop or reduce alcohol consumption (associated with more rapid progression of liver disease)
Discuss ways of avoiding infecting others.
Consider the need to test other family members or close contacts.
Negative HCV RNA result
A positive antibody and negative HCV RNA test indicates a previously resolved infection, but not immunity to further infection.
Patients who are antibody positive but HCV RNA negative should have a second HCV RNA test after 4 to 6 weeks to confirm their negative status.
Further guidance on testing and management
Hepatitis C: information for GPs, Public Health England, 2020.
Hepatitis C: guidance, data and analysis, Public Health England, 2021.
Hepatitis C, NICE, 2020.
The prevention, testing, treatment and management of hepatitis C in primary care, Royal College of General Practioners, 2007
Treatment
In the UK, anyone who is hepatitis C positive and has given informed consent can receive treatment.
Hepatitis C is generally managed according to NICE guidelines, which recommend treatment of chronic hepatitis C with combined pegylated interferon and ribavirin – see:
- Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C
- Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C
Refer all patients with a positive HCV RNA result to a physician with specialist knowledge of the treatment of chronic hepatitis C.
Treatment can successfully clear the virus in more than 90% of patients. Current injecting drug users and people who drink excess alcohol are not usually precluded from treatment.
There is separate guidance for peginterferon alfa and ribavirin treatment for children and young people.
Prevention and control
Currently, there is no vaccine available to prevent hepatitis C infection. Prevention therefore depends on avoiding exposure.
Ask about future travel plans as patients who visit friends and relatives in countries where hepatitis C is endemic are at increased risk of acquiring infection.
Some patients may choose or require medical treatment during their trip, like dialysis, which can put them at increased risk infection with blood borne viruses. Advise patients about this potential risk.
For country specific travel advice, consult the National Travel Health Network and Centre (NaTHNaC).
Hepatitis C is a notifiable disease in the UK. If a case is diagnosed it should be notified to your local health protection team (HPT) who will ensure that information is provided to prevent onward transmission.
The primary care practitioner has a role in advising those chronically infected on how to prevent transmission to others.
Resources
Video: chronic viral hepatitis in migrants
Chronic viral hepatitis in migrants.
NHS guidance about hepatitis C.
The National Travel Health Network and Centre (NaTHNaC) publishes information sheets.
Patient.info has a leaflet for patients about hepatitis C.
The British Liver Trust is a charity which provides resources including a helpline and publications for people with liver disease.
The Hepatitis C Trust is a charity for hepatitis C which aims to increase awareness, provide information, support and representation for people with hepatitis C.
The ‘Hep C, Ki?’ programme is designed to support South Asian people living in Britain to understand risk factors, symptoms and testing for hepatitis C.
Information on hepatitis C and sexual transmission is available from Avert.
The CDA Foundation and Polaris Observatory has a dashboard of country-specific data and global data about hepatitis B and C.
Last updated 14 September 2021 + show all updates
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Updated prevalence statistics, guidance on testing and resources.
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Made editorial changes to meet GOV.UK style.
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First published.